FINANCING FRAMEWORK: RESOURCE REQUIREMENT for the KENYA NATIONAL AIDS STRATEGIC PLAN (KNASP)

H A R A M B E E Republic of Kenya FINANCING FRAMEWORK: RESOURCE REQUIREMENT for the KENYA NATIONAL AIDS STRATEGIC PLAN (KNASP) 2005-2010 POLICY

Preparation and printing of this document was made possible by the financial and technical support of the POLICY Project. The POLICY Project is funded by the United States Agency for International Development (USAID). It is implemented by the Futures Group in collaboration with the Centre for Development and Population Activities (CEDPA) and Research Triangle Institute (RTI). The views expressed herein are not necessarily the views of USAID, the POLICY Project or the collaborating organizations. Kenya National Aids Strategic Plan 2005 2010 Published by: The POLICY Project PO Box 3170 00100 GPO Nairobi, Kenya Edited by: Elizabeth Obel-Lawson Designed by: Winnie Oyuko Printed by: 2005, The POLICY Project 2 Financing Framework: Resource Requirement

Table of Contents ABBREVIATIONS 5 EXECUTIVE SUMMARY 7 I. BACKGROUND 8 I.1 Introduction 8 II. METHODOLOGY 9 II.1 The data 9 II.2 The Resource Needs Model (RNM) 9 II.3 Costing Approach 10 III. ESTIMATES OF FUNDING REQUIREMENTS FOR KNASP, 2005-2010 11 III.1 Estimates of Resource Requirements for Prevention of new infections 11 III.1.1 Provision of HIV/AIDS prevention services for youth in-school and out-of-school 11 III.1.2 Peer education for commercial sex workers 11 III.1.3 Workplace programmes 12 III.1.4 Harm reductions programmes for injecting drug users 12 III.1.5 Uniform services 12 III.1.6 Other vulnerable groups 12 III.1.7 Condom distribution and promotion 12 III.1.8 STI management 13 III.1.9 Expanding VCT 13 III.1.10 Prevention of mother to child transmission of HIV 13 III.1.11 Behaviour change communication (BCC) 13 III.1.12 Ensuring a safe blood supply 14 III.1.13 Post-exposure prophylaxis (PEP) 14 III.2 Improving Quality of Life 15 III.2.1 Providing home based care to those infected with HIV/AIDS 15 III.2.2 Providing palliative care to those infected with HIV/AIDS 15 III.2.3 Diagnostic testing 15 III.2.4 Treating opportunistic infections 15 III.2.5 Offering HIV-infected individuals with OI prophylaxis 16 III.2.6 Ensuring that reliable ARV treatments are available 16 III.2.7 Nutritional support 16 III.2.8 Laboratory tests for ARV therapy 16 III.2.9 Protection of human rights 17 Kenya National Aids Strategic Plan (KNASP) 2005-2010 3

TABLE OF CONTENTS III.3 Mitigation of Socio-Economic Impact 18 III.4 Provision of Support Services 19 IV: TOTAL FUNDING REQUIRED FOR ALL INTERVENTIONS (2005-10) 21 V. ESTIMATES OF FINANCIAL RESOURCES AVAILABLE 23 VI. CONCLUSIONS AND RECOMMENDATIONS 24 VI.1 Conclusions 25 Recommendations 25 Figure 1: Distribution of funding requirements for prevention by 2005-10 14 Figure 2: Distribution of funding requirements for improving quality of life (2005-10) 17 Figure 3: Distribution of funding requirements for key mitigation interventions (2005-10) 19 Figure 4: Funding requirements for key support interventions (2005-10) 20 Figure 5: Total resource requirement (2005-10) 21 Figure 6: Distribution of funding Requirement for 2005-10 22 Figure 7: Comparison of resource requirements and estimated available resources 23 ANNEX 1: SUMMARY OF FUNDING REQUIREMENTS FOR ALL PRIORITY AREAS 26 4 Financing Framework: Resource Requirement

Abbreviations ANC Antenatal Care ART Antiretrovirals ART Antiretroviral Therapy BCC Behavior Change Communication CACCS Constituency AIDS Control Committee CBS Central Bureau of Statistics CDC Centres for Disease Control and Prevention CEDPA Centre for Development and Population Activities CSW Commercial Sex Work ERS Economic Recovery Strategy FHI Family Health International FKE Federation of Kenya Employers FY Financial Year GFAT Global Fund for Aids, TB and Malaria GOK Government of Kenya HAART Highly Active Antiviral Therapy HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome KDHS Kenya Demographic and Health Survey MOES & T Ministry of Education Science and Technology MOH/POLICY Ministry of Health MSM Men having sex with other Men MTEF Medium term expenditure framework NACC National AIDS Control Council NASCOP National AIDS and STI Control Programme OI Opportunistic Infection OVC Orphans and Vulnerable Children PEP Post exposure prophylaxis PEPFAR President s Emergency Plan for Aids Relief PLWHA People living with HIV/AIDS PSI Population Services International RNM Resource Needs Model RTI Research Triangle Institute STI Sexually Transmitted Infection TB Tuberculosis UNICEF United Nations Children Education Fund UNODC United Nations Office on Drugs and Crime Prevention USAID United States Agency for International Development WHO World Health Organisation Kenya National Aids Strategic Plan (KNASP) 2005-2010 5

6 Financing Framework: Resource Requirement

Executive Summary The following report provides a summary analysis of the resources required to achieve the broad objectives outlined in Kenya s National AIDS Strategic Plan (KNASP). The report specifically provides summary information on the key interventions as laid out in the KNASP (2005-2010) and the financial resources required for a credible response to the epidemic. The report also includes the best estimates on the current coverage of those interventions; the current assumptions about HIV/AIDS capacity required to scale up coverage; the best current estimates; and the current and projected HIV/AIDS resources. The data specific to Kenya were obtained using a combination of: 1) key informant interviews with representatives from government, US government agencies, UN institutions, and local universities; 2) a review of six existing HIV/AIDS budgets in Kenya; 3) review of international literature; and 4) various demographic and economic surveys conducted on HIV/AIDS interventions in Kenya. Overall the cost analysis concludes that the total resource requirement for implementing the KNASP in scenario one increase from Kshs. 25 billion in 2005/2006 FY to Kshs. 45 billion in 2009/2010 FY. Of this amount, 26.7% would be allocated to prevention of new infections, 27.3% to improving quality of life, 30% to mitigation of socio-economic impact, and 17.3% to support services. While the current resource envelope is uncertain, it is estimated that approximately Kshs. 24 billion will be available from donors, the government, private sector, household and other stakeholders for HIV/AIDS programmes in 2005/2006. This suggests that it will be necessary to mobilize additional resources during the remaining years of the KNASP in order to achieve its objectives. Even with the projected funding, there would remain a gap of around Kshs. 10 billion that would need to be closed by the year 2009/2010. If we assume a zero growth in the financial resources available for HIV/AIDS programmes, the financial gap would increase from Kshs. 1.2 billion in the FY 2005/2006 to Kshs. 21 billion in 2009/2010 financial year. A number of steps need to be taken by policymakers in Kenya to strengthen Kenya s ability to mobilize resources and reduce the funding gap: The NACC, policy makers and development partners should revise the strategic objectives, target populations and assumed coverage levels. There is need for government to mobilise additional resource for bridging the financing gap. Given the constraints of bridging the financing gap, there is need for NACC to prioritise the priority areas and interventions identified in the 2005-2010 Kenya National AIDS Strategic Plan. Prioritisation can be guided by use of the Goals model, so that resources are spent on interventions that are likely to achieve the greatest impact. Kenya National Aids Strategic Plan (KNASP) 2005-2010 7

I. BACKGROUND 1.1 Introduction In 1999, the Government set up the National AIDS Control Council (NACC) to coordinate a multisectoral approach involving ministries beyond the MOH, as well as the voluntary and private sectors. The Kenya National HIV/AIDS Strategic Plan (KNASP) covers the period from 2005/06 to 2009/10. The KNASP builds on the success of Kenya s ongoing efforts to reduce the prevalence of HIV. The KNASP also represents a key turning point in the country s effort to create a more comprehensive and multisectoral response. Kenya s KNASP provides the overall strategic context and direction for the development of the detailed strategy, which includes a result framework for each priority area to guide and monitor implementation of the national response to HIV/AIDS. The KNASP is designed to provide a clear vision about Kenya s future direction in responding to the HIV/AIDS epidemic. The KNASP is the first step in designing a multisectoral workplan and budget, which will eventually indicate the activities that need to be initiated and the resources required to complete each of these activities. The main purpose of the financing framework of the KNASP is to provide estimates of the resource requirements that would need to be borne by the government, its development partners and other stakeholders in implementing the KNASP. It is imperative to note that the costing of the KNASP is not intended to estimate the resources required to meet every need. It is probably not realistic, for example, to assume that by 2009/2010 every adult in Kenya would receive voluntary counseling and testing (VCT) services, every workplace would have a peer education programme or every infected individual would receive the best available care, etc. Therefore this analysis is based on certain assumptions and targets regarding the level of scaling up that could be realistically achieved by 2009/2010. The idea is to closely align this costing with the goals and objectives of Kenya s KNASP, while developing a budget that is feasible yet adequately ambitious. 8 Financing Framework: Resource Requirement

II. METHODOLOGY II.1 The data Various demographic and behavioral databases were available for use in estimating the potential demand for the various HIV/AIDS services. For example, data were collected from Kenya s 1999 Census; the 1993, 1998 and 2003 Demographic and Health Surveys; the National Health Accounts; NACC National Resource Envelope and Ministry of Education Science and Technology (MOES&T) education indicators. During data collection exercises, several key informants in Kenya were interviewed between November 15th 2004 and December 13th 2004 by the MOH/POLICY Project consultants. Some of the organizations contacted include: the NACC, NASCOP, MOH, MOES&T and the Central Bureau of Statistics (CBS). Other data sources include Centres for Disease Control and Prevention (CDC), Family Health International (FHI), JSI, Population Services International (PSI), and the Population Council. Information was also obtained from United Nation Office on Drugs and Crime Prevention (UNODC), the United Nations Children s Fund (UNICEF), Federation of Kenya Employers (FKE), Amkeni Project, University of Nairobi, various plans such as the 3x5 plan; PMTCT, VCT, HBC and OVC plans were also consulted. Wherever possible, the data from the key informant interviews and the existing documents were utilized. When none of these data sources could provide the required inputs, it was necessary to apply either regional or global cost estimates. II.2 The Resource Needs Model (RNM) The estimation of resource requirements was accomplished by use of the Resource Needs Model (RNM). The Model estimates required resources for a given set of targets in line with the three broad categories of interventions contained in the KNASP prevention of new infections, improving quality of life and mitigation of socio-economic impact. In addition, the resources required for support services were computed as a proportion of the total required for implementing the above broad interventions. The RNM has four key sub-sections: The prevention of new infections section This calculates the cost of 13 prevention interventions under three categories: priority populations; service delivery; and health care systems: Priority populations category includes youth, commercial sex workers and their clients, formal sector employees (workplace programmes), injecting drug users (harm reduction programmes), uniform services and other vulnerable groups such as truck drivers and men who have sex with men (MSM), among others. Service delivery interventions consist of condom distribution and promotion, STI management, voluntary counseling and testing, prevention of mother-tochild-transmission, and behaviour change communication. The health system interventions comprise blood safety and post exposure prophylaxis. The improvement of the quality of life This section estimates the cost of care and treatment interventions which include: homebased care, palliative care, diagnostic testing, treatment of opportunistic infections (OIs), OI prophylaxis in symptomatic patients, highly active antiretroviral therapy (ART), and its associated laboratory support services, training, nutritional support and protection of human rights. Kenya National Aids Strategic Plan (KNASP) 2005-2010 9

METHODOLOGY Mitigation of socio-economic impact This section provides estimated costs of six mitigation interventions: mitigation policy, mitigation advocacy, livelihood and social security, targeted mitigation programmes, community empowerment and human resource planning. Provision of support services The provision of KNASP support services section estimates the cost of five key support services: financing and procurement; communication; coordination and networking; monitoring and evaluation; research; and institutional capacity building. II.3 Costing Approach The inputs used in estimating the cost of a given intervention consisted of three inputs: population in need, coverage targets and unit cost. Using these inputs, the cost of an intervention was estimated using the following formula: Resources (Ksh.) = Population in need x coverage target x unit cost Population This is the number of people that need a given intervention (for example, those needing VCT; for school-based education programmes it would be all students in the appropriate levels; and the need for peer counseling for commercial sex workers would be all commercial sex workers). The number of people in need of each service was determined from the size of the relevant population group (for example, pregnant women, youth, and commercial sex workers) and their behaviours (for example, number of sexual contacts). Coverage target This is the proportion of the population in need that will be reached by a given intervention in a specified period of time. Coverage targets indicate what is feasible and necessary. For example, 75% of people with advanced HIV disease receive ART, 80% of teachers trained in HIV/AIDS. Unit cost This is the amount of resources required to reach one person in a given intervention or the amount of resources required to provide a service, for example, cost per teacher trained, or cost per condom distributed, cost per case of sexually transmitted infection (STI) treated. No assumptions were made with respect to changes in unit costs as programmes are scaled up, that is, inflation or potential efficiencies with scaling up were not factored in. 10 Financing Framework: Resource Requirement

III. ESTIMATES OF FUNDING REQUIREMENTS FOR KNASP, 2005-2010 For purposes of estimating the overall financial resource requirements, three key priorities comprising 29 categories of key interventions and five support services were used. These comprise 13 categories of prevention services, 10 categories of improving quality of life and six categories of mitigating the socio-economic impact of HIV/AIDS. III.1 Estimates of Resource Requirements for Prevention of new infections III.1.1 Provision of HIV/AIDS prevention services for youth in-school and out-of-school Goal for 2010: 100% of all teachers trained in HIV/AIDS and 50% of youth out-of-school reached Cost in 2010: Kshs. 2.883 billion The interventions targeted at the youth were broadly classified as in-school and out-of-school interventions. In the in-school, the costing took into consideration training of teachers at both primary and secondary levels. For that out-ofschool, a peer education programme was the intervention used in the costing exercise. The number of teachers in primary was 178,000 while those in secondary schools were 46,000 in the year 2004. It was estimated that the number of teachers would be 230,089 in primary schools and 39,860 in secondary school by 2010 Central Bureau of Statistics (CBS). The training cost per teaching on HIV/AIDS curriculum ranged between Kshs. 7,000 and Kshs. 10,000 in the African region. Taking this into consideration, a training unit cost of Kshs. 8,500 per teacher was used in the costing exercise. In addition, a regional average unit cost of Kshs. 1,840 ($23) per youth out-of-school was adopted. Based on this information, the total resources required for scaling youth targeted interventions increases from Kshs. 1.017 billion in the 2005/2006 FY to Kshs. 2.883 billion in 2009/2010 financial year. III.1.2 Peer education for commercial sex workers (CSWs) Goal for 2010: 80% of CSWs reached with peer education Cost in 2010: Kshs. 41 million The best available evidence on unit cost is Kshs. 940 ($11.75) based on a study done by Sterling et al. (University of Nairobi). Estimates of the number of CSWs in Kenya varies greatly, but for the costing exercise, it was assumed that CSWs are 3.2% (UNAIDS, Carael) of urban adult female population aged between the ages of 15 and 49. This assumption yielded 46,000 CSWs for the period 2003/2004. The number of CSWs in the Plan period is assumed to grow at Kenyan female population growth rate of 2.4% per year, so that by 2009/2010 there will be about 54,514 out which 80% would be reached by peer education. The total resources required to scale up peer education for commercial sex workers and their clients increases from Kshs. 35.1 million during the 2005/2006 financial year to Kshs. 41 million by 2009/2010 financial year. Kenya National Aids Strategic Plan (KNASP) 2005-2010 11

ESTIMATES OF FUNDING REQUIREMENTS FOR KNASP, 2005-2010 III.1.3 Workplace programmes Goal for 2010: 50% of formal sector employees reached with peer education Cost in 2010: Kshs. 504 million The CBS estimates that the formal sector employees will rise from 1,869,632 in the year 2004 to 2,212,162 in the year 2010. A 50% target by the year 2010 translates to 1,106,081 employees reached. The unit cost of reaching one employee in a workplace based on the experience by AMKENI was Kshs 441 ($5.51). Given these assumptions, the costing exercise yielded approximately Kshs. 210 million for the FY 2005/2006 and Kshs. 504 million for the FY year 2009/2010. III.1.4 Harm reductions programmes for injecting drug users Goal for 2010: 80% of IDUs reached with peer education Cost in 2010: Kshs. 30.6 million The UNODC estimates that there were between 10,000 and 25,000 IDUs in Kenya. For the purposes of costing the plan, it was assumed that there are 25,000 IDUs during 2003/2004. This number was then increased by the Kenyan population growth rate of about 1.9% annually, giving 27,973 in 2009/2010. Peer education and counsellors are the interventions assumed, with a total Kshs. 1,200 ($15) per IDU reached. In addition, training of counsellors was included at Kshs. 40,000 ($500) per counsellor. The number of counsellors to be trained during 2009/2010 was estimated to be 95. The total funding required is projected to scale up from Kshs. 14 million during the 2005/2006 FY to approximately Kshs. 31 million by 2009/2010 financial year. III.1.5 Uniform services Goal for 2010: 100% of uniform services reached with peer education Cost in 2010: Kshs. 164 million Currently there are approximately 100,000 uniform service personnel and this is projected to increase to about 116,944 in 2010. This is based on the assumption that the net increase is about 3,000 persons per year. The unit cost of reaching one uniform personnel is Kshs 1,398 ($17.48). Under these assumptions, the estimated cost of a peer education programme targeting uniform services would be approximately Kshs. 59 million for the FY 2005/2006 and Kshs 164 million for the FY year 2009/2010. III.1.6 Other vulnerable groups Goal for 2010: 100% with peer education Cost in 2010: Kshs. 327 million. It is approximated that there will be 234,000 other vulnerable individuals in 2010. The category of other vulnerable groups includes truck drivers, men who have sex with men and the disabled, among others. The unit cost of reaching one individual is Kshs. 1,398 ($17.48). Based on this information, it will cost about Kshs. 327 million during the FY year 2009/2010 to provide peer education to this group. III.1.7 Condom distribution and promotion Goal for 2010: 60% in commercial sex, MSM and casual contacts 50% in marital contacts when one partner has outside partners Cost in 2010: Kshs. 3.372 billion The condom requirement (male and female) for the whole country is estimated to increase from number 148 million condoms in the FY 2005/ 2006 to 204 million in 2010 FY. The current distribution of condoms of 80% by public sector and 20% by social marketing is assumed to remain constant during the plan period. The estimated unit cost of male condoms distributed by the public sector is Kshs. 14 ($0.18) and Kshs. 13 ($ 0.16) by social marketing. The cost of distributing one female condom is estimated at Kshs. 80 ($ 1). Furthermore, it was assumed 12 Financing Framework: Resource Requirement

CHAPTER III that the current ratio of 95% male condoms to 5% female condoms would remain constant. With these assumptions, the total resource required for distribution of condoms increases from Kshs. 2.181 billion in the FY 2005/2006 to Kshs. 3.372 billion in the FY 2009/2010. III.1.8 STI management Goal for 2010: 90% of symptomatic STI cases treated Cost in 2010: Kshs. 612 million The number of cases of symptomatic STIs based on World Health Organization (WHO) estimation approach was 799,097 and will be approximately 928,981 by 2010. The treatment cost per case used is Kshs. 849 ($ 10.61) (See, Sterling et al., University of Nairobi). The estimated total resource requirement increases from Kshs. 422 million in the FY 2005/2006 to Kshs. 612 million in 2009/2010 FY. III.1.9 Expanding VCT Goal for 2010: 500,000 people counselled and screened for HIV, 700 VCT sites nationally Cost in 2010: Kshs. 886 million The VCT uptake in Kenya shows steadily increasing growth over the past years, with 350,000 counselled and tested in 2004. It is estimated that about 2 million of the adult population will need testing in each of the plan years. The 2 million consists of 500,000 VCT clients and 1.5 million clinical testing. The average unit cost of VCT per person is Kshs. 1664 ($20.80), and this includes the cost of training counsellors. The cost of training one counsellor, incorporated in the average unit cost, was between Kshs. 1,090 and Kshs. 1,272 (NASCOP). During the plan period, about 300 VCT will be established, each at a cost of Kshs. 640,000 ($ 8,000 - NASCOP). The total funding required for this intervention is estimated to increase from Kshs. 740 million in the FY 2005/ 2006 and Kshs. 886 million in the FY 2009/ 2010. III.1.10 Prevention of mother to child transmission of HIV Goal for 2010: 50% of infected pregnant women receive an appropriate and complete ARV regime Cost in 2010: Kshs. 1.450 billion In Kenya there were approximately 948,000 women receiving antenatal care (ANC) in 2003, with ANC utilization at 88% (KDHS, 2004). It is assumed that 80% of the positive pregnant women tested during ANC visits will be put on ARV treatment in 2010. Likewise, it is assumed that 80% of all pregnant women attending ANC will be tested during ANC visits. It is estimated that the cost of HIV screening would be Kshs, 1,473 ($3.38) per woman, while the combined cost of testing and ARV treatment is Kshs. 3,750 ($46.88) per woman (NASCOP). With these assumptions, it estimated that the total resources required for the PMTCT in the FY 2009/ 2010 would be Kshs. 1.450 billion compared to Kshs. 953 million required for the FY 2005/2006. III.1.11 Behaviour change communication (BCC) Goal for 2010: 100% of adult population Cost in 2010: Kshs. 40 million Mass media are components of interventions for behaviour change and communication. It is assumed that six national campaigns would be conducted during the FY 2009/2010. The unit cost of a campaign is based on international cost estimates. The unit cost used in the costing exercise is based on the cost of conducting one campaign in Zambia where one national campaign costs about Kshs. 40 million ($500,000). It is assumed that in the first two years of the KNASP, there will be intense BCC consisting of six campaigns each year and the number of Kenya National Aids Strategic Plan (KNASP) 2005-2010 13

ESTIMATES OF FUNDING REQUIREMENTS FOR KNASP, 2005-2010 campaigns will be scaled down to one campaign during the last phase of the plan. Based on these assumptions, it estimated that the resource requirements for behaviour change communication would be Kshs 240 million in 2005/2006 and Kshs. 40 million in FY 2009/2010. III.1.12 Ensuring a safe blood supply Goal for 2005: 100% of blood supply screened for HIV Cost in 2005: Kshs. 656 million It is estimated that 240,000 units of blood would be required in Kenya in 2010. A cost of screening a unit of blood is Kshs. 2,931 (FHI/National Blood Services). The total funding required range from Kshs. 365 million in the FY 2005/ 2006 to Kshs. 656 million in the FY 2009/2010. III.1.13 Post-exposure prophylaxis (PEP) Goal for 2005: 100% of hospitals providing PEP Cost in 2005: Kshs. 108 million The WHO recommends availability of one PEP kit per 1,000 people. To cover the total population by 2010 would require about 34,964 kits. The unit cost of a kit is Kshs. 3,100 ($ 38.75). The estimated cost is Kshs. 40 million in the FY 2005/2006 and Kshs. 108 million in the FY 2009/2010. The distribution of funding requirements for the various prevention target areas is shown in Figure 1. Figure 1: Distribution of funding requirements for prevention by 2005-2010 Behaviour Change Communication 1.64% Blood safety 5.67% Post-exposure prophylaxis 0.82% Youth focused interventions 21.72% Sex workers and clients 0.43% Workplace 4.03% PMTCT 14.79% Harm reduction programmes VCT 0.26% 9.19% STI management 5.88% Condom provision 31.80% Other vulnerable populations 2.51% Uniform Services 1.26% 14 Financing Framework: Resource Requirement

CHAPTER III As shown in Figure 1, the largest funding requirements for prevention services by 2010 are for condom provision (31.8%), followed by youth focused interventions (21.7%) and prevention of mother-to-child-transmission (14.8%). Voluntary counselling and testing, blood safety, STI management, workplace programmes and other vulnerable populations will account for 9.2%, 5.7%, 5.9%, 4.0% and 2.5% respectively. III.2 Improving Quality of Life III.2.1 Providing home-based care to those infected with HIV/AIDS Goal for 2010: Approximately 75% of PLWHAs requiring home-based care are able to receive it. Cost in 2010: Kshs. 423 million It is projected that by 2010, at least 75% of the PLWHAs in need of home-based care will be covered. The unit cost of providing home-based care is Kshs. 4,000, which is based on PEPFAR estimates. The total cost is projected to increase from Kshs. 265 million in FY 2005/2006 to Kshs. 423 million in the FY 2009/2010 accounting for 3.9% of the total resources allocated for improving quality of care in that year. III.2.2 Providing palliative care to those infected with HIV/AIDS Goal for 2010: Approximately 75% of Kenyans requiring palliative care are able to receive it. Cost in 2010: Kshs. 176 million The population in need of palliative care is estimated at 220,000 HIV adults and 20,000 HIV children. The cost of palliative care is approximately Kshs. 6,000 per infected adult while cost per child is estimated at 50% of the adult cost (Kshs 3,000). During the strategic plan period, palliative care services will be scaled up from 10% in the FY 2005/2006 to 75% in 2009/10. The total funding required for palliative care is projected to increase from Kshs. 163 million in FY 2005/2006 to Kshs. 176 million in the FY 2009/2010. III.2.3 Diagnostic testing Goal for 2010: At least 95% of TB suspects will be offered HIV testing Cost in 2010: Kshs. 147 million The population in need of diagnostic testing includes medical patients and TB patients receiving diagnostic testing. Currently, only 13% of the population in need is receiving the testing. The diagnostic testing programme will be scaled up during the plan period to reach 90% and 95% of the medical and TB patients respectively. The unit cost used is Kshs. 270 per patient per year same as VCT unit cost. This is the unit cost of integrated MOH sites (CDC and NASCOP). Total resources required for diagnostic testing increases from Kshs. 78 million in the FY 2005/2006 to Kshs.147 million in the FY 2009/2010. III.2.4 Treating opportunistic infections Goal for 2010: All HIV + people will have improved access to high quality OIs drugs Cost in 2010: Kshs. 1.249 billion It is currently estimated that only 40% of infected individuals in need of care are able to receive treatment for their opportunistic infections. This will be scaled up to 100% by 2010. OI treatment is more expensive than palliative care and home-based care (Kshs. 20,000 per year per person), but still needs to be strongly prioritised to increase the quantity and quality of life of those infected. It should be noted that the unit cost includes TB treatment (PEPFAR). To provide care services to all those in need, it is estimated that the total resources for OI treatment will be Kshs. 1.249 billion in the FY 2009/2010. Kenya National Aids Strategic Plan (KNASP) 2005-2010 15

ESTIMATES OF FUNDING REQUIREMENTS FOR KNASP, 2005-2010 III.2.5 Offering HIV-infected individuals with OI prophylaxis Goal for 2010: Over 50% of people needing care are able to receive prophylaxis to prevent opportunistic infections. Cost in 2010: Kshs. 314 million OI prophylaxis has been shown to be both a highly cost-effective and affordable way to improve the health of people living with HIV/ AIDS. The estimated average cost of OI prophylaxis is about Kshs. 1,371 per year and the projected number who will be able to receive OI prophylaxis services is about 108,000 by the year 2010. The total funding required for OI prophylaxis is estimated to increase from Kshs. 117 million in the FY 2005/2006 to Kshs. 314 million in the FY 2009/2010. III.2.6 Ensuring that reliable ARV treatments are available Goal for 2010: At least 75% of those appropriate for treatment receive ART Cost in 2010: Kshs. 9.357 billion The cost of ART varies greatly, depending on a number of factors (the availability of generics, the non-drug cost of HAART, etc.). In developed countries, ART medications can cost more than $10,000 per year. However, generic versions of ART medications have been offered at prices as low as $300 per patient per year. Estimates for unit cost are Kshs 75,840 for both males and females. Currently ART is available to about 38, 000 Kenyans, about 9% of those who need it. With a scaled up programme, however, it is estimated that as many as 247,000 Kenyans could potentially have access to ART by 2010. The scaling up of the programme would require Kshs. 9.357 billion in the FY 2009/2010. III.2.7 Nutritional support Goal for 2010: At least 60% of PLWHAs receiving ART in the public, mission, NGOs sites and in need of nutritional support will receive nutritional supplements Cost in 2010: Kshs. 357 million Poor nutrition is linked to HIV/AIDS. Not only does the pandemic compromise the diets of HIV-infected people and their families, but also malnutrition itself increases susceptibility to HIV infection and vulnerability to later illness. HIV-positive people need special nutrition and those taking ARV therapy need advice and supplements. Therefore, nutrition is a vital part of the care package. Currently about 2,500 people are getting nutritional supplements and the estimated cost of providing nutritional supplements per person per year is Kshs. 4,800. The total funding required for nutritional support is estimated to increase from Kshs. 133 million in the FY 2005/2006 to Kshs. 357 million in the FY 2009/2010. III.2.8 Laboratory tests for ARV therapy Goal for 2010: All ART patients receive monitoring tests Cost in 2010: Kshs. 216 million In addition to ARV drug costs, other important costs associated with providing therapy include: HIV tests to establish whether someone is HIV+ and hence eligible for therapy; pre- and posttest counseling; regular out-patient visits to monitor patients for side-effects and to issue supplies of drugs; laboratory tests such as CD4 counts, complete blood counts, viral loads, and chemistry panels to monitor patient health status; and out-patient visits/hospitalizations associated with adverse drug effects. The unit cost associated with laboratory tests for ARV therapy is Kshs. 250 per year. Laboratory tests services will apply to all ART patients. The total funding required is estimated to increase from Kshs. 55 million in the FY 2005/2006 to Kshs. 216 million in the FY 2009/2010. 16 Financing Framework: Resource Requirement

CHAPTER III III.2.9 Protection of human rights Goal for 2010: At least 75% of the PLWAs and those affected by HIV/AIDS will be well informed about their treatment, and legal and reproductive rights Cost in 2010: Kshs. 700 million Safeguarding human rights is an essential part of responding effectively to the AIDS epidemic at individual and national levels. HIV strikes hardest where human rights are least protected, particularly among people and communities on the margins of society, including sex workers, injecting drug users and men who have sex with men. Conversely, safeguarding people s fundamental rights improves their ability to protect themselves and others at risk of HIV infection, helps reduce their vulnerability to HIV, and assists them in dealing with the epidemic s impacts. Protection of human rights programmes includes: awareness campaigns on ART services and the importance of getting tested; information on treatment, legal and reproductive rights; advocacy on PLWHAs on human rights, and establishment of legal and policy framework for protection of OVC human rights among others. Protection of the human rights component is estimated to cost about 10% of the total annual costs on improvement of quality of life. The resources required to scale up human rights activities increases from Kshs. 606 million during the FY 2005/2006 to Kshs. 700 million in the FY2009/2010. Figure 2 below indicates that the largest funding requirement is for ARV therapy, which accounts for 61.7% of the total funding for improving quality of life. Treatment of opportunistic infections accounts for 16.5% while protection of human rights and home based care accounts for 8% and 3.9% respectively. Figure 2: Distribution of funding requirements for improving quality of life (2005-2010) Palliative care 1.86% Protection of human rights 8% Nutritional support 2.72% Home-based care 3.89% Diagnostic testing 1.26% Treatment of opportunistic infections 16.53% Training 0.61% OI prophylaxis 2.39% ARV therapy 61.67% Lab HAART 1.52% Kenya National Aids Strategic Plan (KNASP) 2005-2010 17

ESTIMATES OF FUNDING REQUIREMENTS FOR KNASP, 2005-2010 III.3 Mitigation of Socio-Economic Impact This section of the KNASP is still a grey area and the targets provided are not quantified. The general targets to be realized by 2010 are listed below. Greatly increased understanding by policy makers and planners of the impact of HIV/ AIDS, particularly for vulnerable groups and sectors (Advocacy). National policy on mitigation developed and explicitly reflected in core GOK policy and finance processes including ERS, MTEF and annual budget (Mitigation policy). Impact of HIV/AIDS on livelihood and social security in Kenya quantified and effective counter measures designed and implemented (Livelihood and social security). Increased coverage of mitigation programmes targeting at most seriously affected social and economic sectors, and most vulnerable groups such as OVC, CSW and widows, among others (Mitigation programmes). Increased information available at community level on socio-economic impact of HIV/ AIDS and appropriate responses. In addition, mitigation initiatives mainstreamed into existing local structures, including CACCS, local governments, and school boards, among others (Community empowerment). Human resource policies in public and private sectors reflect impact of HIV/AIDS on productivity (Human resource planning). The general nature of the above targets resulted in basing the costing for mitigation interventions on the proportion of the total resource requirements for implementing the KNASP. The NACC task force members working on this component recommended that at least 30% of total resource financial requirements be allocated to mitigation to ensure a fair distribution of resources among the interventions. It is important to mention that the suggested 30% of total resource requirements to be allocated for mitigation of socio-economic impact of HIV/ AIDS is not the output of the Resource Needs Model. Further to this recommendation, the experts suggested weights, which were then used to distribute the 30% among the broad targets areas. The weights are presented in Table 1 below. It should be noted that the cost of resources for mitigation programmes, was to a large extent represented in the resources needs for the OVC programme. The OVC cost component of the mitigation programmes was adopted from the costed OVC strategy for Kenya developed by UNICEF and the Ministry of Home of Affairs. The OVC programme targets the 50% of OVC living below the poverty line as those most in need of support in each of the four categories, namely education subsidy, skills training, hot meal and child care. Table 1: Weights used in allocating resources to mitigation interventions Target area 2005/06 2006/07 2007/08 2008/09 2009/10 Advocacy 0.05 0.05 0.03 0.02 0.01 Mitigation policy 0.035 0.035 0.02 0.02 0.03 Livelihood and social security 0.05 0.05 0.03 0.03 0.03 Mitigation programmes 0.125 0.125 0.19 0.135 0.125 Community empowerment 0.03 0.03 0.02 0.02 0.02 Human resource planning 0.01 0.01 0.01 0.005 0.005 Total 0.30 0.30.030 0.30 0.30 18 Financing Framework: Resource Requirement

CHAPTER III The unit costs per child per year used are Kshs. 1,600 ($ 20) for primary education, Kshs. 3,200 ($40) for secondary education, Kshs. 7,000 ($88) for training, Kshs. 45 ($ 0.56) for a meal or Kshs. 16,425 per year and Kshs. 3,000 ($38) for child care. The total estimated resource requirements for mitigation of socio-economic impact of HIV/AIDS increases from Kshs. 7.568 billion in the FY 2005/2006 to Kshs. 13.516 in the FY 2009/2010 as shown in Figure 3. The largest funding requirements are for mitigation programmes (58.9%) followed by livelihood and social security, which will account for 12.1% by 2010. Community empowerment, mitigation policy and mitigation advocacy will account for 7.7%, 9.1% and 9.7% respectively of the total funding requirement for mitigating socioeconomic impact of HIV/AIDS. III.4 Provision of Support Services The detailed prevention, improving quality of life and mitigation of socio-economic impact need to be supported with financing and procurement, communication, coordination and networking, monitoring and evaluation, research and institutional capacity building. These activities may be costed through detailed workplans. The activities under support services were estimated as proportions of the overall KNASP resource requirements. The actual percentages in each of the plan years are shown in Table 2. Overall, support services will take about 21% in the FY 2005/2006 and 15% in the FY 2009/2010. The total estimated cost for provision of support services will increase from Kshs. 5.311 billion in the FY 2005/2006 to Kshs. 6.627 billion in the FY 2009/2010. The distribution among the major support services is illustrated in Figure 4 for 2005-2010. The largest estimated component is monitoring and evaluation, at 32.7% of the total required resources for the support services. Institutional capacity building and research components will account for 11.5% each of the total funding required under this priority. Figure 3: Distribution of funding requirements for key mitigation interventions (2005-2010) Human resource planning 2.53% Mitigation policy 9.09% Community empowerment 7.72% Mitigation advocacy 9.67% Mitigation programmes 58.86% Livelihood and social security 12.11% Kenya National Aids Strategic Plan (KNASP) 2005-2010 19

ESTIMATES OF FUNDING REQUIREMENTS FOR KNASP, 2005-2010 Table 2: Weights used in allocating resources to support services Target area 2005/06 2006/07 2007/08 2008/09 2009/10 Financing and Procurement 3% 2.5% 2% 2% 2% Communication, Coordination and Networking 6% 6% 5% 5% 5% Monitoring and Evaluation 8% 8% 6% 4% 4% Research 2% 2% 2% 2% 2% Institutional Capacity Building 2% 2% 2% 2% 2% Total 21% 20.5% 17% 15% 15% Figure 4: Funding requirements for key support interventions (2005-2010) Institutional capacity building 11.53% Financing and procurement 13.56% Research 11.53% Monitoring and evaluation 32.72% Communication, coordination & networking 30.66% 20 Financing Framework: Resource Requirement

V: TOTAL FUNDING REQUIRED FOR ALL INTERVENTIONS (2005-2010) The funding requirements are presented in two scenarios. In scenario one, only branded ARVs are used in the costing of ART while in scenario two, only generic ARVs are used. In both scenarios, the cost of ARVs is assumed to reduce by 10% every year. Based on these assumptions, the total resource requirements for all priority areas increase from Kshs. 25.226 billion in the FY 2005/2006 to Kshs. 45.054 billion in the FY 2009/2010 in scenario one. However, in scenario two, the estimated required resources will increase from Kshs. 23 billion in the FY 2005/ 2006 to Kshs. 41 billion in the FY 2009/2010. Figure 5: Total resource requirement (2005-2010) 50000 Kshs (millions) 45000 40000 35000 30000 25000 20000 15000 10000 7,680 9,011 11,702 13,590 13,590 14,847 17,488 20,550 17,488 25,226 28,854 30,737 33,194 36,218 37,248 40,424 41,363 45,054 5000 0 2000/01 2001/02 2002/03 2003/04 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 Total resource requirements (scenario 2) Total r esource requirements (scenario 1) Note: 2000/01-2003/04 are actual resources. The actual resources for 2003/04 of Kshs. 13.590 billion are similar to the Kshs. 13.334 billion estimated using the Resource Needs Model. Kenya National Aids Strategic Plan (KNASP) 2005-2010 21

TOTAL FUNDING REQUIRED FOR INTERVENTIONS (2005-2010) The distribution of funding requirements for the strategic plan period (2005-2010) is illustrated in Figure 6. The largest resource requirement for the entire plan period is for mitigation of socio-economic impact (29.6%); followed by improvement of quality of life (26.9%) while prevention and support services account for 26.4% and 17.11%, respectively. Figure 6: Distribution of funding requirement for 2005-2010 Provision of support services 17.11% Prevention 26.39% Mitigation of Socio - economic impact 29.60% Improving quality of life 26.90% 22 Financing Framework: Resource Requirement

V. ESTIMATES OF FINANCIAL RESOURCES AVAILABLE Figure 7 illustrates the level of resources that will be required for the FY 2005/2006 to FY 2009/2010 and the documented and projected local and international spending for which funding is available to achieve the objectives identified in the 2005-2010 Kenya National Strategic Plan (KNASP). A review of spending on HIV/AIDS indicates that there is likely to be a gap in the available resources without additional funding. For example, assuming a 10% annual growth rate of financial resources, the level of funding for HIV/AIDS programmes from donors, private sector, out-of-pocket, local and international NGOs and the government for the FY 2005/2006 is estimated to be approximately Kshs. 24 billion. In 2006/2007, donors, government, households and private sources are estimated to spend Kshs. 26.4 billion on HIV/ AIDS programmes. In 2007/2008 FY, there could be an increase in spending to as much as Kshs. 29 billion, due to the availability of additional funds from USAID, the Global Fund for AIDS, TB and Malaria (GFATM) and development partners. However, even with the projected funding, there would remain a gap of around Kshs. 10 billion that would need to be closed by the year 2009/2010. If we assume a zero growth in the financial resources available for HIV/AIDS programmes, the financial gap would increase from Kshs. 1.2 billion in the FY 2005/2006 to Kshs. 21 billion in 2009/2010 financial year. Assuming a constant growth in the NRE, and scenario two, which assumes that the cost of ARV drugs will significantly decline, the funding requirements for the FY 2005/2006 would be less than the financial resources available. However, the financial gap is expected to grow significantly from approximately Kshs. 4.9 billion in the FY 2006/2007 to Kshs. 25 billion by 2010 financial year. Figure 7: Comparison of resource requirements and estimated available resources 50,000 45,000 40,000 35,000 30,000 00 23,063 25,226 28,854 30,737 33,194 36,218 37,248 40,424 41,363 45,052 20,000 15,000 10,000 5,000 0 2005/06 2006/07 2007/08 2008/09 2009/10 Total Resource requirements (scenario 2) Total Resource requirements (scenario 1) NRE (assuming zero growth rate) NRE (assuming 10% annual growth rate) Kenya National Aids Strategic Plan (KNASP) 2005-2010 23

VI. CONCLUSIONS AND RECOMMENDATIONS VI.1 Conclusions The costing exercise suggests that the available resources may not be adequate to meet the requirements of the KNASP, given the targets. For instance, if the resource gap of Kshs. 10 billion in 2010 cannot be closed with additional resources the consequences would be significant. If the resources available to all components are reduced accordingly, each component would receive about 23% less than required. For prevention it is possible that resources could be concentrated on the most effective interventions so that the number of infections averted would not be reduced much. But the equity of prevention coverage would certainly suffer as less money would be available for some general population interventions. In the area of quality of life the consequences would be more severe. Since most treatment funding is for ART, it would mean that instead of reaching 75% of those in need of treatment by 2010 we could reach only 58%. Similarly within the mitigation component, 23% fewer orphans would receive vital support. Recommendations Based on this, the following recommendations are suggested: The NACC, policy makers and development partners should confirm or revise the strategic objectives, target populations and assumed coverage levels. There is need for government to mobilise additional resource for bridging the financing gap. Given the constraints of bridging the financing gap, there is need for NACC to prioritise the priority areas and interventions identified in the 2005-2010 Kenya National AIDS Strategic Plan. Prioritisation can be guided by use of the Goals model, so that resources are spent on interventions that are likely to achieve the greatest impact. 24 Financing Framework: Resource Requirement

Annex 1: Summary of funding requirements for all priority areas TYPES OF HIV/AIDS COSTS OF HIV/AIDS INTERVENTIONS (KSHS MILLIONS) INTERVENTIONS 2005/06 2006/07 2007/08 2008/09 2009/10 2005-2010 PREVENTION Priority populations Youth focused interventions 1,017 1,416 1,853 2,341 2,883 9,509 Sex workers and clients 35 37 38 39 41 190 Workplace 210 278 349 425 503 1,765 Harm reduction programmes 14 20 24 27 31 116 Uniform services 59 83 109 135 164 550 Other vulnerable populations 118 166 217 271 327 1,099 Service delivery Condom provision 2,181 2,426 2,747 3,095 3,472 13,921 STI management 422 466 513 561 612 2,575 VCT 740 789 777 830 886 4,021 PMTCT 953 1,363 1,357 1,351 1,450 6,476 Behaviour change communication 240 240 120 80 40 720 Health care Blood safety 365 426 487 548 656 2,482 Post-exposure prophylaxis 40 55 70 85 108 360 Total Prevention Cost 6,395 7,765 8,661 9,788 11,173 43,782 IMPROVING QUALITY OF LIFE Home-based care 265 323 345 380 423 1,737 Palliative care 163 217 116 158 176 830 Diagnostic testing 78 95 113 130 147 563 Treatment of opportunistic infections 1,668 1,712 1,364 1,384 1,249 7,376 OI prophylaxis 117 163 212 261 314 1,067 Lab HAART 55 93 139 173 216 677 ARV therapy 4,000 5,231 7,458 8,352 9,357 34,397 Training 27 39 57 69 81 273 Nutritional support 133 164 259 299 357 1,212 Protection of ruman Rights 723 795 835 835 835 4,022 Total Cost For Improving Quality of Life 7,228 8,833 10,897 12,041 13,156 52,154 Kenya National Aids Strategic Plan (KNASP) 2005-2010 25

Summary of funding requirements for all priority areas (cont.) TYPES OF HIV/AIDS COSTS OF HIV/AIDS INTERVENTIONS (KSHS MILLIONS) INTERVENTIONS 2005/06 2006/07 2007/08 2008/09 2009/10 2005-2010 MITIGATION OF SOCIO-ECONOMIC IMPACT Mitigation policy 883 1,076 724 808 1,352 4,843 Mitigation advocacy 1,261 1,537 1,087 808 451 5,144 Livelihood and social security 1,261 1,537 1,087 1,213 1,352 6,449 Mitigation programmes 3,153 3,842 6,881 8,287 9,236 31,400 Community empowerment 757 922 724 808 901 4,113 Human resource planning 252 307 362 202 225 1,349 Total Cost of Mitigation of Socio - Economic Impact 7,568 9,221 10,865 12,127 13,516 53,298 PROVISION OF SUPPORT SERVICES Financing and procurement 770 770 770 770 770 3,850 Communication, coordination & networking 1,514 1,844 1,811 2,021 2,253 9,443 Monitoring and evaluation 2,018 2,459 2,173 1,617 1,802 10,069 Research 505 615 724 808 901 3,553 Institutional capacity building 505 615 724 808 901 3,553 Provision of Support Services 5,311 6,303 6,203 6,025 6,627 30,469 OVERALL TOTAL (KShs million) 25,226 30,737 36,218 40,424 45,054 177,659 OVERALL TOTAL (US$ million) 315 384 453 505 563 2,221 26 Financing Framework: Resource Requirement